Billing, Payment and Reconciliation Issues Galore
The current 834-related enrollment issues we’re hearing about will lead to payment-related issues; which in turn will lead to coverage and claims payment issues. Stories about incorrect subsidy calculations impacting the accuracy of premium amounts surfaced shortly after healthcare.gov went live. These stories arose from the state-based exchanges and we’ve yet to hear from the FFM.

The important thing to keep in mind is that very few – if any – exchanges have actually deployed functionality for submitting HIPAA 820 (Premium Payment/Order Remittance Advice) to their QHP partners. Of course the fact that these accounting and payment functions have not yet been developed only increases the likelihood of major heartburn arising in Q1 of 2014.

Topics You Won’t Hear About from Main Stream Media
But some things aren’t very sensational nor easy to understand so you won’t hear about them from the main stream media. Here are some accounting and payment related issues you likely won't hear about:

Multiple Sources of Payment
Since all those receiving a subsidy will necessitate a split-billed premium where more than one party is responsible for payment of the premium, the likelihood of premium payment issues leading to eligibility issues is certain to increase. What are the policy and technical requirements for processing members receiving subsidies who do not pay their portion.? Under what conditions can the member re-enroll? Must they pay all their costs that are in arrears?

People Grow Older - Subscribers are not Dependents
There is a dearth of guidance from CMS on handling common life events like aging off dependents, aging into Medicare, how retroactive terminations will be communicated, etc via the 834 transaction.

For families, these processing scenarios are made worse as each scenario needs to clearly differentiate between the subscriber and dependents. Anyone who’s familiar with the 834 transactions knows how finicky the “2300 Loop” can be! :)

The Most Wonderful Time of the Year?

All of the above are being worked on in the most hectic, cut-up month of the year: December. Years from now, I don’t suspect this will be one Christmas that will be memorialized among the “tales of glories of Christmases long, long ago.”

For more information on health insurance exchanges and other health IT topics, be sure to follow me on Twitter.

Friday, November 22, 2013

Last December I offered 3 reasons why I thought the deployment of health insurance exchanges (HIX) would flounder in October 2013. Now I’m going to share 3 more reasons why I believe health insurance exchanges will continue floundering into 2014 and likely beyond. Here’s reason #1:

By law, health insurance exchanges are the system of record for all enrollment transactions originated by a consumer to a qualified health plan (QHP.) The 834 Benefit Enrollment and Maintenance transaction is used by HIX’s to submit new enrollments, changes to enrollment and disenrollments to QHP’s. Unfortunately, there are not any clear operating rules defining how the 834 is to be used for the myriad of new enrollment, change enrollment and enrollment termination transactions that result from the life events a consumer will experience. Moreover, the 834 transaction was never widely adopted across the healthcare industry. Most QHP’s and 3rd parties use their own variation of the 834 transaction to process key enrollment events into their backend systems.

So far, 834’s have trickled out of the exchange and once the flood starts (assuming it ever does), the variability in how QHP’s have implemented their 834 handling will surface.

After initial enrollment, all subsequent enrollment changes must be originated through the exchange, not the QHP. So when someone loses their job, gets a job, has a child, or has some other life event they need to go back to the HIX and make their required changes. And the 834 exchange process between the HIX and QHP starts over again.

Currently the business rules and edits associated with effecting these changes are largely performed by the QHP. Any incomplete or incorrect data must be caught by the QHP. Then the QHP has to work with the consumer and HIX to correct the issues. It’s not clear there are sufficient automated edits and controls in place to handle the wide range – but common – enrollment scenarios.

So m belief is that these enrollment issues will create undue heartburn and lead to other issues as 2104 unfolds. I will describe these other issues in subsequent posts.

For more information on health insurance exchanges and other health IT topics, be sure to follow me on Twitter.

Friday, November 15, 2013

Earlier this week, attorney and health care blogger David Harlow made a post titled “Health Exchange Enrollment: Speed of Light or . . . Molasses.” Harlow suggested that people need to “cool their jets” about the low numbers of ACA enrollees because “early enrollment is supposed to be slow” - apparently because that’s the way it was in Massachusetts back in 2006-2007.

So early enrollment in the ACA is supposed to be slow in 2013 because the experience in Massachusetts was ‘slow’ in 2006? Seriously? These two roll-outs hardly seem comparable:

1. The ACA has been touted all over the media for 3-4 years now. One cannot watch TV, read anything anywhere, listen to the radio, browse the web and/or drive anywhere without being inundated with information about the benefits of enrolling in Obamacare. Moreover, the ACA was front and center through last years presidential election and a high-visibility Supreme court case.

2. Hundreds of millions of dollars in paid marketing/advertising has been spent on the ACA. An equal or larger amount of exposure has been provided via supportive main stream media.

3. Internet access and technologies supporting awareness and enrollment are way more ubiquitous now – nearly a decade later - than when MA was being implemented in 2006.

4. ACA subsidies benefit those up to 400% FPL – Massachusetts up to 300%.

So far, only the easy to deploy and no-cost/low-cost parts of Obamacare have been implemented: primarily kids on their parent’s plan, elimination of pre-ex on children and removal of lifetime limits. As Harlow states, current ACA enrollee counts are likely dominated by the long-uninsured and under-insured. Yes, it’s still early, human nature is to procrastinate and a turnaround might occur. Maybe. But given the above, the overall low number of enrollees these first 6 weeks, the remaining as yet widely un-publicized issues and the challenge getting the “young invincibles” to enroll, the belief that the Obamacare death spiral may have officially begun is probably not be the fantasy Harlow makes it out to be.

Friday, August 16, 2013

When I first started out on Twitter,
I had a limited number of topics I was interested in and I wasn’t following
many people. It wasn’t too difficult to
separate the wheat from the chaff. But as I started to follow more people and
as I expanded my topics of interest, I developed an approach to maximize the
value of my Twitter feed. Here’s an overview of my approach.

1. Use
a good desktop Twitter client – paired with its mobile counterpart

Personally, I
think there are only two choices for a good Twitter client: Tweetdeck or
Hootsuite. Each are very similar and
each have some unique features. I’m
actually using both right now but plan to move to only one of them – someday.
In the meantime, I’ve rarely had any tweet limit or throttling issues by using both at once.

2. Use
an extra monitor – or multiple monitors

My desktop
includes three monitors and I use one 24” monitor largely dedicated to
Tweetdeck and Hootsuite. I have the resolution set at the highest level
possible.

3. Use
multiple columns & smallest font size possible

Since I have a
large monitor set with a high resolution, I configure my Twitter clients to use
multiple columns – with each column dedicated to a specific purpose. To squeeze
in even more columns, I set the font size as small as possible.

4. Setup
columns for specific purposes & areas of interest

I have about a
dozen columns set up in my Twitter clients and I use hashtags, lists, custom
search terms and the standard Twitter filters (Timeline, Interactions,
Mentions, Favorites, etc.) to customize the tweets displayed in each column. Of
all the techniques possible, I think my use of lists and custom search
terms provides me with the most capability and flexibility to manage the signal
to noise ratio.

A note on lists: I
use all the lists Twitter lets me create to segregate what I consider certain
high-value Tweeps. I’m constantly adding to and pruning these lists based on
the topics and areas of interest of these Tweeps. This helps call out good
signals. Lists are very useful for me
because I follow just about everyone who follows me (except for the XXX, MLM
and obvious nutcases) and the sheer volume of tweets from 1000’s of people is
clearly unmanageable.

5. Tag
and forward

Many times,
especially when I’m browsing using my smart phone, I see things that I want to
share with others or save for later when I have more time to review them. In these cases I usually add a tag or short
note and forward the tweet to myself via email.
I used to mark these as favorites but then decided I might be sending
the wrong message since some of the items I marked would not be considered a ‘favorite.’

Sunday, August 11, 2013

The complexitiesand
overhead associated with implementing EHR’s, health insurance exchanges (HIX),
ICD-10, health information exchanges (HIE) and ACO’s all get a lot of attention
among those involved with health information technology. And there are a few
other programs that many health care entities – mainly health plans and payers
– have been scrambling to implement the last few years; all in an effort to
comply with government regulations.

Part of the ACA, the "3R's" program is designed to protect health
plans against adverse risk selection and mitigate the impact of high cost
membership. It’s required of those selling individual plans within and outside of the
exchanges.The mechanism creates
substantial data collection and processing challenges.

The Coordination of Benefits Agreement (COBA) Program
establishes a standard method of sharing enrollee eligibility data and Medicare
adjudicated claim data between CMS and other health insurance organizations. It
provides for the establishment of unique identifiers (COBA IDs) to be
associated with each contract and creates a national repository for COBA
information.

The above programs include complex data capture, processing
and exchange requirements that are exacerbated by the need to collect data from
disparate source systems - some of which are maintained by external business
partners. Addressing the data access, quality assurance and data transfer
challenges associated with these programs – while simultaneously addressing
other mandates like health insurance exchanges, ICD-10 and health information
exchanges is (HIE) and ACO’s – is a big deal; particularly in light of the
dearth of knowledgeable, experienced resources.

Tuesday, August 6, 2013

Previously, I offered some of my thoughts about The Good and The Bad aspects of the recent #HIT100 event.In
this post I’ll share thoughts and facts about The Ugly part of the event. To be
clear, The Ugly are aspects of the event that, in my opinion, should not have
occurred, are ethically shaky and/or tarnished the overall spirit of the
#HIT100 event.

Note: I suppose this post is not going to endear me to those who may have been involved with some of these aspects. Those who know me, have followed me
for any length of time or who may have been unfortunate enough to only sample a
subset of my tweets know that I'm not the most politically correct person. I’m
not calling out specific accounts and perhaps some of the accounts involved may
not even be aware of their involvement.

The Ugly

1. Voter Fraud – One Vote per Person Please!

What ever
happened to one vote per voter? It’s a shame a few people – maybe from my home
town of Chicago – voted for their candidate(s) multiple times. For example, the
following was observed:

a. A company having multiple twitter accounts
used each account to vote for their candidate(s.)

b. One dad voted for his son using – at least -
3 separate accounts; all within one minute of each other.

c. Some created a new twitter account
specifically to vote for their candidate. Some of these accounts didn’t even
have any followers or even make any other tweets after voting!

There’s
nothing wrong with promoting oneself and many of those making the top 20 did a
little promotion. But some were a few that were just over the top with the following - even a few days into the event after several requests were made to avoid excessive RT's and "non-voting" chatter.

a. RT’ing every single tweet that mentioned
them.

b. Thanking every single tweet that mentioned
them and then RT’ing that tweet just for good measure. Gratitude is a nice
thing – within moderation.

c. Creating specific instructions and a
template to make it easy for people to nominate themselves or their candidate –
or was that their boss?

I imagine all the above also made tallying the results more cumbersome?

3. Company Affiliations

A couple
company accounts really went overboard with their enthusiasm for their brand
and executive. I’ve read several posts about the #HIT100 being limited to
individuals and I totally agree.

4. Naysayers

There’s one
(or two or three) in every crowd.
Shortly after the event started, a couple disgruntled tweeps started
complaining that most of those at the top of the list were not deserving of
their rank. Talk about painting all the pennies with the same brush!

Another
moaned and groaned that some high-level health care IT folks were not high
enough up the list or not even listed - even though most of the people they
noted are not active users of social media and/or even involved with
information technology.

5. Hashtag Hijackers and Hookers

The #HIT100
hashtag got hijacked a few times and quite a few XXX and other ‘cretins of the
Net’ came out in their attempt to collect clicks. I suppose this is actually a sign of the
growing reach of the #HIT100?

Fortunes and Influence Do
Change

One web site
that listed the 2013 #HIT100 nominees noted the following:

Many of the
"winners", identified by their Twitter handles, will be familiar to
most readers, but a comparison with last year's list reveals how fortunes, or
perhaps influence, can rise and fall as the years go by.

Indeed
fortunes and influence can wax and wane as years go by. And in the case of this
year’s #HIT100, some fortunes and influence – at least as measured by ranking
in the HIT100 – rised and fell due to a few people who decided to Ugly Up in
an attempt to garner votes for themselves and/or their candidates.

Monday, July 29, 2013

In a previous post, I offered some thoughts about The Good aspects of the #HIT100 event. In this post I’ll share thoughts and facts about The Bad aspects of #HIT100 event. In a future post I’ll address what I think are some of The Ugly aspects.

The Bad (ok, not ‘bad’ – but could use some improvement)To be sure, the following are not necessarily “bad,” but they're not among “The Good” or “The Ugly” – but perhaps aspects that might be addressed in next year’s #HIT100 event.

1. More tweets =
more votes?

Neil Versel (@nversel) notes in a recent post that many highly ranked HIT100’ers are prolific tweeters and supposes there’s a
direct correlation between noise and list ranking. To me, ‘noise’ implies junk
tweets, excessive RT’s, and lots of 1 on 1 banter. This is not always the case
for some people; witness #2 Justin Barnes (@HITAdvisor) with less than 500
tweets (as of 7/27).

2. “A” is
better than “Z?”

Remember all those kids in grade school who were always
first up because they had a last name that started early in the alphabet? Well, that’s not always a undesirable thing
because in the #HIT100, people with identical vote counts are assigned a
ranking based on how their Twitter handle sorts relative to others having the
same count.

If you got 8 votes this year, you were better off being
@annelizhannan (#65) vs. @WittRZ (#78) since that Twitter handle starting with an 'A' vs. a 'W' resulted in a 14 place improvement even though both of these worthy #HIT100 nominees received the same number of votes. Note: I don't imply that either #HIT100 member is better or worse than the other - they just represent the edge cases for those receiving 8 votes.Technically, if nominees were ranked by
number of votes, the #HIT100 would actually be the #HIT31. :)

3. Few votes
separated the majority of the #HIT100

Only 19 votes
separated 74 nominees! And only three votes separated @HJluks (#89) and
@harrygreenspun (#61) – a rise of 28 places! So in my opinion this is a major
blemish on the ranking process.

4. Adding the #hcsm and #hitsm hashtags
clouded many Twitter streams

There sure were a lot of extraneous tweets with #hcsm and
#hitsm. As @tyrulallc tweeted: “Going cross-eyed scrolling through all the
#HIT100 nominations in my home feed.”

5. What else was
not so good about #HIT100?

What Else?

In my next post I’ll share some thoughts that I – and others
I’ve heard from – have about some of The Ugly aspects of the #HIT100
event. I’ll then close with a post
outlining some ideas for addressing some of The Bad and The Ugly aspects; and
what I consider are the qualities of a good #HIT100 nominee.

Sunday, July 28, 2013

No one can argue the #HIT100 event hasn’t
helped socialize the importance and value of using social media to share
information and ideas about information technology and services in the healthcare
space. It’s definitely a “good thing.” Alas, like most good things that grow in
size and prominence over time, there are always a few bad and ugly aspects. And
the #HIT100 event is no exception.

In this post I offer some thoughts and
facts that I – and others I’ve read from – have about The Good aspects of the #HIT100
event. I’ll share more about The Bad and
The Ugly of the #HIT100 event in two future posts.

The
Good

1. Generates awareness of people using social
media to advance information technology in the healthcare space

Over 30 – or about one-third – of the 2013 #HIT100
nominations didn't make the 2012 #HIT100 list. Personally I’ve become aware of
about 15 new sources of health information technology and related services who frequently share via
social media channels.

2. Helps socialize the importance and value of
information technology and services in the healthcare space

Or, as David Shaywitz (@DShaywitz – ranked #67)
noted: “A freakishly smart way to
generate buzz.”3. Offers recognition to those who invest their
time in social media

There’s no doubt being included in the #HIT100
list brings attention. I can attest: Last year I (@ShimCode - ranked #29) was ranked in 5th place
in the #HIT100 and received a lot of recognition including several interviews,
100’s of new followers (who work in the health IT industry) over the ensuing
days, an increase in being quoted in articles covering my area of expertise and
literally dozens of inquiries as to whether I was interested in new job
opportunities.

4. Helps individuals develop their personal brand

This is a natural by-product of my previous
comment. Indeed I’ll mention the flip side
of this in my future post on The Bad aspect of the #HIT100 event.

As we all learned in kindergarten, if
you can’t say anything nice about someone or something, don’t say anything at
all. So now I've shared what I think are the nice/good things about the #HIT100 event. In my next two posts I’ll share
some thoughts that I – and others I’ve heard from – have about The Bad and TheUgly aspects of the #HIT100 event.

Wednesday, July 17, 2013

A couple of years ago I made a pledge to myself to make a
blog post at least 4-5 times a month. But blogging on a regular basis takes focus
and dedicated effort; and due to some major new, positive events on the work
and home front, I’ve not made the time needed to work this blog.

Today I’m starting at it again. And I credit @HealthBizDcoded for providing this post as the inspiration to get me going again.
Being listed along with some real health IT blogging pros has incented
me to clean up my act and get back at it.
Thanks @HealthBizDcoded!

In addition to continuing a focus on ICD-10, I plan to offer
information and opinion on the IT and service-related aspects on the topics
listed below. Why? Because these are the primary areas I’m
involved with and focus on every work day (and many weekend days too).

Collecting various data points, interfacing to 3rd party
vendor for measure calculations and receiving actual measures and reports.

Medicare Advantage EOB

Project to provide a new explanation of benefits complying
with new format requirements.

Risk Adjustment & Reporting - Edge Server and 3R’s

Project to deploy the Direct Data Entry (DDE) Edge Server
mandated by CMS. Includes services to address provider contracting and
incentives, suspect identification and outreach, chart review and HCC coding,
member outreach and medical risk management and interfacing to various vendors.

Coordination of Benefits Agreement (COBA)

Project to improve the way eligibility and Medicare claims
payment data within a claims crossover context is exchanged.

Accountable Health System

Project to rollout IT and services infrastructure to support
an Accountable Care Organization (ACO) including provider network and referrals,
provider channeling, Capitation payment and risk sharing, and medical/care
management tools.

ICD-10

The original topic that got me started in blogging:
ICD-10. I’ll continue a focus on
testing, implementation and post-implementation topics.

So if you’re interested in the IT and service-related
aspects of the above aspects of healthcare, check back here a few times each
month for more information. You can also
get more of the same by following me on Twitter at @ShimCode